HCIS - Heartland Communications Internet Services

Company

Consent to Disclose

Both a law passed by Congress and Federal Communications Commission rules impose a general duty on telephone companies to protect the confidentiality of our customer information. As a telephone company we may use, disclose, or permit access to your customer information in these circumstances: (1) as required by law; (2) with your approval; and (3) in providing the service from which the customer information is derived.

Heartland Communications Internet Services, Inc. / Aero Communications, LLC are obligated to disclose your customer account information to any person you designate if you make the request in writing by filling out the form provided below and providing at least one form of photo identification proving you are the customer listed on the account. A copy of your calling records can be picked up at our main office located at 1301 Broadway in Paducah, KY. For security purposes we do not email these records or provide them in digital format. Please allow a minimum of 7 days to process the request.

I, _________________________________________________________________(Customer) authorize and grant permission to Aero Communications, LLC to disclose my customer calling information on the phone number listed below.

Telephone number: ( ) _______________-_______________________________

Disclose Information to:

Name:_____________________________________________________________________________________________________

Address:___________________________________________________________________________________________________

City:_______________________________________ State:_______________________________________________ Zip:_______

Email Address:_________________________________________________________________@___________________________

Alternate Telephone Number:___________________________________________________________________________________

I would like the phone records for (month/day/year) ________________________to(month/day/year) ________________________.

I also confirm that the address below is the physical address where the telephone number is located.

Physical Address: ____________________________________________________________________________________________

(City)______________________________________________________________________________________________________

(State)___________________________________________________________(Zip)______________________________________

Date: _______________/_________________/_________________
(Month/Day/Year)

Signature:___________________________________________________________________________________________________
(Customer Account Holder)

2nd Signature:_______________________________________________________________________________________________
(Customer Account Holder - if an additional name is on the account.)

Notary Public:_______________________________________________________________________________________________

Notary Public (Print Name):____________________________________________________________________________________

Date: _____________________________________________________________________________________________________

Commission Expires: ________________________________________________________________________________________